What is the initial management for a child presenting with croup symptoms?

Initial Management of Croup in Children

Administer oral dexamethasone 0.15-0.6 mg/kg (maximum 10 mg) immediately to all children presenting with croup symptoms, regardless of severity, and add nebulized epinephrine (0.5 ml/kg of 1:1000 solution, maximum 5 ml) for moderate to severe cases with stridor at rest or respiratory distress. 1, 2

Immediate Assessment

Upon presentation, rapidly evaluate for:

• Severity indicators: stridor at rest, use of accessory muscles, respiratory rate, oxygen saturation, and ability to speak/cry normally 1
• Life-threatening signs: silent chest, cyanosis, fatigue/exhaustion, or poor respiratory effort requiring immediate intervention 1
• Alternative diagnoses: bacterial tracheitis, epiglottitis, foreign body aspiration (especially with sudden choking episode), retropharyngeal abscess 1, 3, 4

Avoid radiographic studies unless you suspect an alternative diagnosis, as clinical assessment is sufficient for croup 1, 2

Treatment Algorithm by Severity

Mild Croup (No Stridor at Rest)

• Give oral dexamethasone 0.15-0.6 mg/kg (maximum 10 mg) as a single dose 1, 2, 4
• Observe for 2-3 hours to ensure symptom improvement 5
• No nebulized treatments needed 5

Moderate to Severe Croup (Stridor at Rest, Respiratory Distress)

• Give oral dexamethasone 0.15-0.6 mg/kg (maximum 10 mg) immediately 1, 2
• Add nebulized epinephrine 0.5 ml/kg of 1:1000 solution (maximum 5 ml) 1, 2, 5
• Administer oxygen to maintain saturation ≥94% 1, 2
• Observe for at least 2 hours after the last epinephrine dose to assess for rebound symptoms 1, 2, 5

Alternative corticosteroid option: Nebulized budesonide 2 mg is equally effective when oral administration is not feasible 2, 6

Hospitalization Criteria

Admit to hospital if the child requires 3 or more doses of nebulized epinephrine 1, 2, 5. This updated threshold (rather than the traditional 2 doses) reduces hospitalization rates by 37% without increasing revisits or readmissions 7, 1, 2

Additional admission criteria include:

• Oxygen saturation <92% 1, 2
• Age <18 months 1, 2
• Respiratory rate >70 breaths/min 1, 2
• Persistent difficulty breathing despite treatment 1, 2

Critical Pitfalls to Avoid

• Never discharge within 2 hours of nebulized epinephrine administration due to risk of rebound symptoms (epinephrine effects last only 1-2 hours) 1, 2, 5
• Never use nebulized epinephrine in outpatient settings where immediate return is not feasible 1, 2, 5
• Do not skip corticosteroids in mild cases—they reduce symptoms and prevent hospitalization even in mild disease 2, 5, 3, 4
• Avoid humidified or cold air therapy—current evidence shows no benefit 1, 2
• Do not routinely prescribe antibiotics—croup is viral in etiology 2, 3

Discharge Criteria

Discharge home when:

• Stridor at rest has resolved 2, 5
• Minimal or no respiratory distress 2, 5
• Adequate oral intake 2, 5
• Parents can recognize worsening symptoms and return if needed 1, 2, 5

Provide clear return precautions: instruct parents to return immediately if the child develops difficulty breathing, inability to drink, cyanosis, or extreme fatigue 1, 2

Supportive Care

• Use antipyretics for comfort and to help with coughing 1, 2
• Minimize handling to reduce metabolic and oxygen requirements 1, 2
• Ensure adequate hydration 1
• Position children under 2 years with neutral head position (roll under shoulders) to optimize airway patency 1